HomeMy WebLinkAboutBLDP&G-17-003583 /Y1RP : PfiRe6c :
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_�_f_rC CITY L. %N �^y f)UUT 1-1 -I MA DATE orm PERMIT# I�/7 6
JOBSITEADDRESS ' c-/rEAC lr() L . I OWNER'S NAME Liee-tn.r7)r c4P cild;reran I
POWNER ADDRESS _ . _ TEL fFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Ej RESIDENTIAL LY
PRINT
CLEARLY NEW:Li RENOVATION:Li REPLACEMENT:LI PLANS SUBMITTED: YES® NO®
FIXTURES 1 FLOOR-4 BSM 1 _,
2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ; !
. se
_ ll ....
. --
CROSS CONNECTION DEVICE I r
DEDICATED SPECIAL WASTE SYSTEM I .-I
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM i_____i iI___. :._-- -. __ _ I___ _ i _ _ __ .__.__' ._ ,.- .; -__ _ .__-__
DEDICATED GRAY WATER SYSTEM __. II _ _._' _i_ ____ _ ___ '.I____ . _. ._-i ___ _
DEDICATED WATER RECYCLE SYSTEM _ __ _ i _ _ 1-___I _- _- -. I
DISHWASHER _
DRINKING FOUNTAIN i WI ,; . ,_ 11 _. _
FOOD DISPOSER11101111n;
-,
FLOOR/AREA DRAIN
� '
INTERCEPTOR(INTERIOR I I _ ;NI
KITCHEN SINK iI
! _ , ___ _ , .-
LAVATORY i
ROOF DRAIN '
SHOWER STALL ;i J I _r. � L I_____
SERVICE/MOP SINK _._
TOILET
URINAL
i:._
WASHING MACHINE CONNECTION _ .. .;I ------', ! ___.a __. ; _ .,�_.-.._'�..._..._ ____...,:..T._... - -_--. _--..---_._ __....
WATER HEATER ALL TYPES ._ _._. __ I
WATER PIPING I�I v.__ I _-
OTHER mas
`n _ I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO Ej
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L;;9 OTHER TYPE OF INDEMNITY ® BOND ID
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Li AGENT El
• SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in ccr^°nse vith all P 'neat provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME f- 111_0 3 cl e J LICENSE# L bap 1 ( SIG ATURE
MP VI JP Ell CORPORATION YS#,;1.% ' .JPARTNERSHIPLJ# ' . LLC[1# _
COMPANY NAME ,a.(acer,:�e...C_t►_Hs__ �,'.. IADDRESS iL._ r za4 ._L'_ d�______ __.____- ___- .j
J
CITY w. /., -r. o,..4A - STATE .(Y)A I ZIP O 1�7' TEL (66°9 CI V k
FAX bof'79 o-.3-1 1 CELL EMAIL
JAN 11 2017
artBUILDINgLDEPARTMUIT
By
/17h9P / Rc z/
MASSACHUSE 1 I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
. .
i CITY 1 Town of `/A_R(Y)Q t 3 MA DATE'Lis i )7 .1 PERMIT#AzAi)-1 7^' ✓
JOBSITE ADDRESS: 7 -i4r,- d-PP r_4 1,,n 1 OWNER'S NAME t F-1 ,- n D," �,44>. r.)-f- (
OWNER ADDRESS j _ _ TEL �_ _ ,i
TYPE DR — R
PRINT OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL;i RESIDENTIAL 0
CT.E.aRr.Y NEW:i= RENOVATION:Li REPLACEMENT:! I PLANS SUBMITTED: YESO NO LI
APPLIANCES 7. FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - 1 t 4 4 t r 0 s- .it . 1, � 4_. µ
BOOSTER M. -t <- a ' .. ':.�_ t ! _ '_ _C I . 5 .
CONVERSION BURNER 3— i_i' _ !__ Ai .., 1 ___ `�,.._--.I
COOK STOVE _ _ —_ � __ -- -. r __..i
DIRECT VENT HEATER _.. _ i 1 ;x ,� t, .
DRYER , I I _ jI _ -WI it _':^1,
FIREPLACEi___u! _ : i },
FRYOLATOR Ls- I? 1 =-, . IL. — — •-_. t
FURNACE ---- 1 d . (1.1•1 -I_ ___,..1 _->> _____ i___,' -_--_
GENERATOR _E '-___I, - _- _.4
GRIT I F i -.... ._____$ _ _. _ .a= _
INFRARED HEA I ER ,_' _i e MI-1__ �� _ AL_ 0_' _
LABORATORY COCKS 1 / _ 1, i . .1 i ._% . r•': • 5-,;.i''_ .O- 1
MAKEUP AIR UNIT _ - -- ' _ '_____.. _ ' ' f �__11�. •o.'° I
OVEN -WM' ' `,►�.! '�1.1! •
POOL HEATER . 'M' _ -WIZ ••_ t '' U i .'
ROOM I SPACE HEA I ER - -.:; `,__
ROOF TOP UNIT • W. __ 'Wow I_. )
UNff HEATER -_ _.____if r-.J.._.---.4 ___-_ LI. ;I. .��. ,_ 1--1
UNVENTED ROOM HEATER -1
WA I ER HEATER $ __A__ _ -;
OTHER I _ $ i__� .� _ _ O. f _w'—.
s E ?
INSURANCE COVERAGE �--•�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LE NO !l
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE INDEMNITY E BOND r__-1
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to e best of my Iaiowledge
and that all plumbing work and installations performed under the perrnrt issued for this application wit be in compliance with all c provision of the
Massachusettb State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME. e,uc 0 fri c-B i_ r-) a LICENSE it.1 I 0° M NATURE
MP iI ` MGF Li JP El JGF(,J LPGI f J CORPORATION la#'S 8(,_ F G i PARTNERSHIP[3#1 LC U#i—1
COMPANY NAME } Z`c ADDRESS I I (J 0-/
CITY W. `/r,r'rrr - STATE ZIP, a;673 ITELr -eEk _7/f �5. .
F S&)7rto-h7ti51 CELLI IEMAILI t
JAN 11 2011 '
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BUILDING�EPARTMENT
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